Monday, December 24, 2012

One of the most
controversial comorbidities in children with ASD is the co-occurrence of
Attention Deficit Hyperactivity Disorder (ADHD). Comorbidity refers to the
presence of more than one diagnosis occurring in an individual at the same
time. Although there continues to a debate about ADHD comorbidity in ASD,
research, practice and theoretical models suggest that comorbidity between
these disorders is relevant and occurs frequently. For example, a study of
comorbid psychiatric disorders in children with ASD found that approximately
71% of cases had a least one comorbid psychiatric disorder, with the most
common comorbidities being social anxiety (29%), ADHD (28%), and Oppositional
Defiant Disorder (28%). Although the current DSM-IV-TR hierarchical rules
prohibit the concurrent diagnosis of ASD/PDD and ADHD, there is a relatively
high frequency of impulsivity and inattention in children with ASD. In fact,
ADHD is a relatively common initial diagnosis in young children with ASD. Some
researchers suggest that there are sub-groups of children with ASD with and without
ADHD symptoms.

Current Research

Although comorbid
psychiatric disorders in children with ASD have been studied previously, there
is a need to examine the impact of co-occurring ADHD symptoms in children with
ASD. A recent study published in the journal Pediatrics
evaluated the frequency of co-occurring ADHD symptoms in a well-defined cohort
of children with ASD and examined the relationship between ADHD symptoms and
both adaptive functioning and health-related quality of life as reported by
parents or other primary caregivers. The purpose of the study was to: (a)
document the frequency of parent-reported ADHD symptoms in a large, geographically
diverse population of children with ASD, and (b) further evaluate the differences
between children with ASD and ADHD symptoms and those with few or no ADHD
symptoms, with an emphasis on parent-report measures of adaptive functioning
and health-related quality of life (HRQoL). Based on a review of previous
studies, the researchers hypothesized that children with ASD and comorbid ADHD
symptoms would have poorer HRQoL and greater impairment in adaptive functioning
than children with ASD and few or no ADHD symptoms.

Method and Outcome
Measures

The research was conducted
as part of the activities of the Autism Speaks Autism Treatment Network (ATN),
a registry collecting data on children with ASD across 14 sites in the United
States and Canada. A total of 3066 children and adolescents ages 2 to 18 were eligible
for participation in the study. All participants had a clinical diagnosis of
ASD based on one or more diagnostic measures.

Parents completed the Child
Behavior Checklist (CBCL), a parent/caregiver measure of a variety of problems
exhibited during childhood. T-scores on 2 ADHD-related scales from the CBCL were
used to indicate the presence of ADHD symptoms. Participants were divided into
groups based on whether their parents/caregivers rated them as having
clinically significant T-scores on the Attention Problem and Attention Deficit
Hyperactivity Problem subscales of the CBCL. Parents were interviewed to
complete the Vineland Adaptive Behavior Scales, Second Edition (VABS-II). Standard
scores from VABS-II and raw scores from the parent report version of Pediatric
Quality of Life Inventory (PedsQL) were then compared between groups with the
use of multivariate analyses.

Results

Results indicated that 41%
of the 3,000 participants had elevated scores on one CBCL ADHD-related subscale
and 19% on both subscales. Analysis of responses to the PedsQL revealed that
the ASD/ADHD group had lower scores in all health-related areas measured (School
Functioning, Physical Functioning, Emotional Functioning, and Social Functioning)
in comparison with the group of children with ASD alone. The ASD/ADHD group
also obtained statistically significantly lower scores on all adaptive behavior
domains of the VABS-II (Communication, Daily Living Skills, Socialization, and
Adaptive Composite) when compared with the group of children with only ASD.

Conclusion and
Implications

Overall results of the
study suggest greater impairment in adaptive functioning and a poorer
health-related quality of life for children with ASD and clinically significant
ADHD symptoms in comparison with children with ASD and fewer ADHD symptoms. This
supports previous research on the negative relationship between ADHD symptoms
and the development of functional life and other adaptive skills and provides further
documentation regarding the relationship between comorbid symptoms and overall
health-related quality of life. The results also suggest the need for
additional research. For example, it would be important to determine if
children with ASD that meet diagnostic criteria for ADHD differ significantly
from children with ASD and ADHD symptoms in the areas of adaptive skill
development and HRQoL, as well as other important areas. This question is
particularly important with the impending publication of DSM-V which will
remove the restriction on the comorbid ADHD diagnosis in children with ASD.

These results of the study
have important implications for practitioners in health care, mental health,
and educational contexts. Externalizing behavior problems, including ADHD
symptoms, have been found to have a strong negative relationship with family
functioning and parenting stress in children with ASD. Reducing ADHD symptoms
in children with ASD, in addition to treating core symptoms, may result in greater
improvement in HRQoL and adaptive functioning. Improving adaptive functioning
is especially important in that a child’s level of adaptive functioning can
directly influence their type of educational setting and future adjustment. Children
with better adaptive skills have more opportunity to participate in grade-level
activities with typical peers. Consequently, clinicians and health-care professionals
should screen for symptoms of ADHD in children with ASD and, if present,
consider these symptoms when developing interventions and treatment protocols.

Monday, December 10, 2012

The American Psychiatric Association voted to
approve the revised fifth edition of its Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) on December 1, 2012. The manual is used by clinicians nationwide to
diagnose mental health conditions and will be published in spring 2013. Among
other changes, the revision introduces fundamental changes in the diagnosis of
autism. It collapses the previously distinct autism subtypes, including autistic
disorder, Asperger’s disorder (syndrome), and pervasive developmental
disorder-not otherwise specified (PDD-NOS) into a single unifying diagnosis of
autism spectrum disorder (ASD). Further, the current DSM-IV-TR three
symptom domains (triad) of social impairment, communication deficits and repetitive/restricted
behaviors, interests, or activities will be replaced with two domains, social
communication impairment and repetitive/restricted behaviors or interests.
Changes also include greater flexibility in the criteria for age of onset and
addition of symptoms not previously included in the DSM-IV-TR such as sensory
interests and aversions.

The new DSM-5 criteria for
ASD have created significant controversy with predictions that it would exclude
many individuals from an autism diagnosis and thus make it difficult for them
to access services. Critics suggest that the new criteria are too narrow and
will leave out a large number of people currently diagnosed with Asperger
syndrome and PDD-NOS). However, early studies suggest that fears that many
individuals will be excluded appear to be largely unfounded. For example, a recently published
field trial suggests that the revisions increase the reliability of diagnosis,
while identifying the large majority of those who would have been diagnosed
under the DSM-IV-TR. Of the small numbers who were not included, most received
the new diagnosis of “social communication disorder.” The DSM-5 criteria also
proved highly reliable, meaning that two different clinicians using them were likely
to diagnose the same person with the same disorder.

A comprehensive study
published in the American Journal of Psychiatry also lends support to
application of the DSM-5 criteria. Researchers evaluated the new criteria in
children with DSM-IV diagnoses of pervasive developmental disorders (PDD) and
non-PDD diagnoses and found that the DSM-5 criteria identified a majority of
children with clinical DSM-IV diagnoses. The study used three data sets from 4,453
children with DSM-IV clinical PDD diagnoses and 690 with non-PDD diagnoses
(e.g., language disorder). Items from a
parent report measure of ASD symptoms (Autism Diagnostic Interview–Revised) and
a clinical observation instrument (Autism Diagnostic Observation Schedule) were
matched to DSM-5 criteria and used to evaluate the sensitivity (percentage individuals
with ASD who are correctly identified) and specificity (percentage of individuals
without ASD who are correctly identified) of the DSM-5 criteria and current
DSM-IV criteria when compared with clinical diagnoses. According to the
results, the majority of children with clinical diagnoses of PDD met the DSM-5
ASD criteria according to item scores on the Autism Diagnostic
Interview–Revised and the Autism Diagnostic Observation Schedule. Application
of the DSM-5 criteria demonstrated adequate sensitivity across all groups, On
the basis of either parent report or clinical observation, DSM-5 sensitivity
ranged from 0.97 to 0.99 for any PDD. Overall, the sensitivity values of the
DSM-5 and DSM-IV criteria were comparable. Moreover, the accuracy of non-spectrum
classification (specificity) made by DSM-5 was better than that of DSM-IV,
indicating greater effectiveness in distinguishing ASD from non-spectrum
disorders such as language disorders, intellectual disability, attention deficit
hyperactivity disorder, and anxiety disorders. The researchers conclude that “Based
on symptom extraction from previously collected data, our findings indicate
that the majority of children with DSM-IV PDD diagnoses would continue to be
eligible for an ASD diagnosis under DSM-5. Additionally, these results further
suggest that the revisions to the criteria, when applied to records of children
with non-PDD diagnoses, yield fewer misclassifications.”

Autism researcher Geraldine Dawson,
chief science officer for Autism
Speaks, commented that although the new criteria appear to be effective, it
will be critical to monitor so that children don't lose services. According to an
open letter
from Dawson, “We are reassured that the DSM-5 committee has stated that all
individuals who currently have a diagnosis on the autism spectrum, including
those with Asperger syndrome, will be able to retain an ASD diagnosis. This
means that no one with a current diagnosis on the autism spectrum should “lose”
their diagnosis because of the changes in diagnostic criteria. Also, the
committee has stressed that the new DSM-5 criteria represent a “living document
in which changes can and likely will be made as new studies are conducted.”
“Today, after careful consideration, we are acknowledging the APA’s approval of
the DSM-5 with cautious optimism” she said.

All 208 pages of this book are filled with
research-based information about the best practices schools should adhere to
when assessing and intervening with children in schools. The author does a
wonderful job presenting all of the data, facts, figures and statistics in a
very structured layout that is straightforward, practical and convenient to
access.

As the prevalence of Autism Spectrum
Disorders continues to expand, this book is a crucial addition to any school
library. It is no longer possible for school systems to ignore or continue to
deal with developmental delays in piecemeal fashion and Lee Wilkinson has put
together an excellent comprehensive manual to guide school personnel in
addressing these issues.The increased prevalence of Autism
Spectrum Disorders requires professionals to identify children as early as
possible in their school experience. Whether a child comes to school diagnosed
or not Lee Wilkinson’s book is the perfect guide for schools to follow in order
to set the ball in motion to access the earliest intervention services
possible.I found this to be a very user-friendly
book as evidenced by the following:

The two case studies Wilkinson includes in the book helps the
reader comprehend all the information presented by actually seeing the
best practices in action and how they apply in real life situations.

The author was very thoughtful to include a glossary of terms and
acronyms to help those who are new to the arena of Autism Spectrum
Disorders translate meaning and decipher what the abbreviated codes stand
for quickly.

Frequently asked questions and an abundance of forms such as
worksheets and checklists make this book a convenient one stop shopping
experience for the reader.

The “Quick Reference” boxes at the end of each chapter help to
summarize the chapter information even further or highlight a specific
strategy that was presented.

I was extremely impressed with the detailed “index to best
practice recommendations” which not only summarizes the process at the
various stages but the index also supplies the corresponding page for the
reader to access more detailed information about each practice.

As a school social worker who worked in
the public school system with special needs children for seventeen years this
book would have been a very helpful tool for all school based professionals to
access. With the rising incidence of children being diagnosed on the Autism
spectrum, this guide should be required reading for all direct service
providers who work with children in the school setting. On behalf of the Autism community I extend a sincere
thank you to Lee Wilkinson for this impressive and most valuable resource!

Monday, December 3, 2012

The American Psychiatric Association’s recommendation
to delete (remove) Asperger’s disorder as a separate diagnostic category from
the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) was approved on December 1st by the by the Association's Board of Trustees.
Specifically, DSM-5 will include a new category of “autism spectrum
disorder,” which subsumes the current diagnoses of autistic disorder
(autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive
developmental disorder not otherwise specified (PDD-NOS). This new category
reflects DSM-V Work Group members’ conclusion that “a single spectrum disorder”
better describes our current understanding of the neurodevelopmental disorders.

The objective of the new ASD criteria is that every individual who has
significant “impairment” in social-communication and restricted and repetitive
behavior or interests (RRBI) meet the diagnostic criteria for autism spectrum
disorder. Language impairment/delay will no longer be a necessary criterion for
diagnosis of ASD. Therefore anyone who demonstrates severe and sustained
impairments in social skills and restricted, repetitive patterns of behavior,
interests, or activities in the presence of generally age-appropriate language
acquisition and cognitive functioning, who might previously have been given a
diagnosis of Asperger’s disorder, would now meet the criteria for the new category
of ASD. The criteria also feature dimensions of severity that include current
levels of language and intellectual functioning. Additionally, symptom examples
are expected to be provided for all ages and language levels, so that ASD will
not be overlooked in persons of average or superior IQ who are experiencing
“clinical” levels of difficulty. Full details of all the revisions will be
available in May 2013 when the American Psychiatric Association's new
diagnostic manual is published.

Critics of the new category of ASD expressed
concern that individuals would lose their current diagnoses and no longer be
eligible for special services. But the revision will not affect their education
services, experts say. The term "autism spectrum disorder (ASD)," is
used by many experts and practitioners in the field. The new category will
include the complete autism spectrum, from mild to the more severe forms of the
disorder. Catherine Lord, an autism expert at Weill Cornell Medical College in
New York and member of psychiatric group's autism task force, commented that
anyone who met criteria for Asperger's Disorder (syndrome) in the current manual
(DSM-IV-TR) would be included in the new diagnosis. Lord also comments that
although there has been much controversy about whether there should be separate
diagnoses, "Most of the research has suggested that Asperger syndrome
really isn't different from other autism spectrum disorders." "The
take-home message is that there really should be just a general category of
autism spectrum disorder, and then clinicians should be able to describe a
child's severity on these separate dimensions." Another reason for the
change is that some states and school systems don't provide services for
children and adults with Asperger's, or provide fewer services than those given
an autism diagnosis, she said. Autism researcher Geraldine Dawson, chief
science officer for the advocacy group Autism Speaks, said small studies have
suggested the new criteria will be effective. But she commented that it will be
critical to monitor so that children don't lose services. While including
Asperger’s Disorder under the new category of “autism spectrum disorder” may
well require a period of transition and adjustment, the proposed “dimensional”
approach to diagnosis will likely result in more effective identification,
treatment, and research for individuals on the spectrum.

A more detailed summary and discussion of
the proposed revisions to DSM disorders and criteria are available at
<http://www.dsm5.org>

Sunday, December 2, 2012

The Individuals with
Disabilities Education Improvement Act of 2004 (IDEA) (P.L. 108-446) (http://idea.ed.gov/) guarantees a free and
appropriate public education (FAPE) in the least restrictive environment (LRE) for
every student with a disability. The LRE provision mandates that “to the
maximum extent appropriate, children with disabilities, including children in
public or private institutions or other care facilities, are educated with
children who are not disabled, and special classes, separate schooling, or
other removal of children with disabilities from the regular educational
environment occurs only when the nature or severity of the disability of a
child is such that education in regular classes with the use of supplementary
aids and services cannot be achieved satisfactorily.”In general, inclusion (or inclusive
education) with typical peers is often considered to be the best placement option for students
with disabilities. However, a study published in Pediatrics,
the official journal of the American Academy of Pediatrics, calls into question
whether or not inclusive education actually leads to better outcomes in the long
term for children with autism.

The Study

Researchers from the
University of Alabama at Birmingham and Johns Hopkins University sought to
determine whether the proportion of time spent in an inclusive educational
setting, a process indicator of the quality of schooling for children with
autism, improves key outcomes. The participants were 484 children and youth
educated in special education with a primary diagnosis of autism in the
National Longitudinal Transition Study-2 (NLTS2). The NLTS2 is a 10-year study
of youth with disabilities who were receiving special education services in
public or state-supported special schools. The NLTS2 uses a nationally
representative sample of youth in special education who were between the ages
of 13 and 16 on December 1, 2000.

The primary exposure of
interest in this analysis was the proportion of time the youth spent in a
general education classroom. A school program questionnaire was used to collect
data on the courses that each student took during the 2003 school year and
whether each course was taken in a general education or special education
classroom. The proportion of time spent in an inclusive setting was categorized
as 0%, 1% to 74%, or 75% to 100% of courses taken in a general education
classroom.

Key Outcomes

Three outcomes were
assessed in the study’s analysis: (1) not dropping out of high school, (2) any
college attendance, and (3) a cognitive functional scale. Youth were coded as
not dropping out if the parent reported that they graduated, received a
certificate or General Educational Development certificate, or were still in
high school at the time of data collection. Any college attendance was based on
parent report of whether the youth attended any type of postsecondary school in
the previous 2 years, including postsecondary classes to earn a high school
degree, a 2-year or 4-year college, or postsecondary vocational school. The
functional cognitive scale measured a combination of parent-reported cognitive,
sensory, and motor skills used in performing daily activities (such as counting
change). Parents rated their child on a scale of 1 (“not at all well”) to 4
(“very well”) for each of these skills. The rating for each skill was added to
create the functional cognitive scale, which ranged from 4 (not at all well for
any of the skills) to 16 (very well for all of the skills).

Results

Compared with children
with autism who were not educated in an inclusive setting, children with autism
who spent 75% to 100% of their time in a general education classroom were no
more likely to attend college, not drop out of high school, or have an improved
functional cognitive score after controlling for key confounders. The
researchers state that “In general, our analyses suggest that inclusivity does
not improve educational or functional outcomes for children with autism.”They also note that although the link between
inclusivity and outcome remains weak, “inclusive education” that is well
implemented and supported might have substantial benefits. Recommendations for
further research include investigation of educational and functional outcomes from
data on large samples of children in real-world settings. There is also a need
for developing future indicators to measure the “quality” of special education
for children with autism. This includes a careful description of the learning
environment and experiences within and between communities as well as key
measures specific to the characteristics and education of children with autism.
The authors conclude that the study illustrates the challenges of understanding
the effect of real-world services and treatments and that a “A fuller
understanding of inclusivity and other potential measures of educational
quality may have to wait for better data and methods.”

Foster, E. M., &
Pearson, E. (2012). Inclusivity an Indicator of Quality of Care for Children With Autism in
Special Education? Pediatrics, 130, S179-S184. DOI: 10.1542/peds.2012-0900P

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The objective of bestpracticeautism.com is to advocate, educate, and informby providing a best practice guide to the screening, assessment, and intervention for school-age children on the autism spectrum. Timely articles and postings include topics such as screening, evaluation, positive behavior support (PBS), self-management, educational planning, IEP development, gender differences, evidence-based interventions (EBI) and more. This site also features up-to-date information on scientifically validated treatment options for children with ASD and a list of best practice books, articles, and links to organizations. Designed to be a practical and useful resource, bestpracticeautism.com offers essential information for psychologists, teachers, counselors, advocates and attorneys, special education professionals, and parents.

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